Staff Health Form – NAD Youth

To be completed by a staff member’s doctor/physician by June 10, 2023. Physical exams made before July 23, 2023 will not be accepted. If you have any questions about this form please email [email protected] with subject header "YLC Staff Completed Health Form".

Name *

First Middle Last

Date of health exam *

Birthdate *

Gender *

Height *

Weight *

Blood pressure *

Hair color *

Eye color *

Please check if the staff member had any of the following health problems. If you checked yes, please explain the comment box provided below.

Health History Information

Elaborate on any of the items checked above:

Add any other history that is not listed above:

Any chronic or recurring illnesses? *

Add info about chronic/recurring illnesses: *

Any dietary requirements, restrictions, or allergies? *

Add dietary requirements, restrictions, or allergies: *

Has the staff member been exposed to anyone who is at risk for latent Tuberculosis infection or has TB disease? IF so - when was the campers last Tuberculosis test?

Does the staff member carry an epinephrine pen? *

For what? *

Any additional physical/mental health considerations?

Is the staff member currently on medications? *

Please include drug name, route, dosage, and schedule. Please state what will happen, including onset behavior, if the staff member does not take the medicine. *

Immunization History DPT

Please list ALL of your immunization shots including year(s) of immunization and last booster.
(e.g. Tetanus/Diphtheria - shot 1998, booster 2008)

Here's a list of typical shots:
Tetanus/Diphtheria
Tetanus (alone)
Oral Polio (Sabin)
Injectable Polio (Salk)
Measles (Rubeola)
Measles (Rubella)
Mumps

By submitting this form, I certify that I have on this date examined the above named staff member and that on the basis of my examination and the medical history as furnished to me, I have found no reason that would make it medically inadvisable for this staff member to participate in physically strenuous activities.

Licensed Physician's name *

First Last

Licensed Physician's address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Licensed Physician's daytime phone number *

Licensed Physician's emergency/evening phone number *

Signature

2023 YLC Staff Health Form